Medicare

​​​​​​​​​​​​​​​​​​​​​​​​​​Approximately 13% of nursing home patients rely on Medicare for their daily care. Medicare Part A covers ​skilled nursing facility care for a short-stay after a qualifying inpatient hospital stay. Patients often receive nursing and therapy care, and many often return home after their stay. Medicare does not cover long term services and supports. Adequate Medicare policy and reimbursement is crucial in ensuring access to high-quality skilled nursing care for America’s seniors. ​​​​​​​​​​​

​Medicare Part A Skilled Nursing Facility Prospective Payment System

 
Each year, the Centers for Medicare and Medicaid Services updates Medicare fee-for-service payment policies and rates for skilled nursing facilities under the Skilled Nursing Facility Prospective Payment System (SNF PPS) for the next fiscal year. Learn more about the latest payment rule and access member-only resources. 

 ‭(Hidden)‬ FY 2019 Medicare SNF PPS Rate Calculator Tool

DISCLAIMER:  This FY 2019 Medicare SNF PPS Rate Calculator is not an official CMS calculator.  This calculator, with your facility-specific inputs, provides estimated SNF PPS rates and revenues based on tables from the final rule.  We anticipate some technical correction updates from CMS, and possible minor calculation or rounding errors for some situations, but overall this tool should provide a close estimate on the revenue impact of all the payment adjustments that go into effect in FY 2019.  This tool includes the 2.4% market basket rate increase, the SNF QRP adjustment (for affected facilities), the SNF VBP incentive payment multiplier, and sequester adjustment.

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FY 2019 Medicare SNF PPS Rate Calculator Tool (Effective 10/01/2018)

​Medicare Part B Fee Schedules

 
DISCLAIMER:  These files are not official CMS files, although every effort was made to assure their accuracy for your needs.  If in doubt, always refer to your Medicare contractor and/or the CMS website. 

​News & Resources

 ‭(Hidden)‬ AHCA/NCAL Medicare Resources

 ‭(Hidden)‬ Medicare News

 Accountable Care Organizations

​ACO Toolkit - Members Only

  • Module 1 – Overview of the ACO Program: This module provides an overview of the structure, financial model and regulatory requirements of ACOS as well an understanding of how ACOs work including who can participate, beneficiary attribution, financial incentives, quality reporting and waivers.
  • Module 2 – Role of PAC and SNFs within ACOs: Building on Module 1, Module 2 provides a more detailed understanding of the role and opportunity for SNF/PAC into the ACO model.
  • Module 3 – ACO-SNF Contracting Guide: Module 3 highlights the key components in the development and negotiation of contracts between SNFs and ACOs including the key components of a contract, recommendations on terms that should (or should not) be in the contract, and important considerations for contract negotiation.

​Medicare Managed Care

 
Managing Medicare Managed Care pulls together relevant existing AHCA/NCAL managed care resources.

Medicare Advantage (MA) is the managed care program within Medicare. It provides beneficiaries with the option to receive their Medicare benefits through private health plans. MA continues to grow rapidly and has doubled over the past decade to over 26 million people in 2021, which is 42% of all Medicare beneficiaries (see below). This growth is expected to continue as more and more individuals age 65+ are opting to have their care be managed by a private health plan and are attracted by the additional benefits that are offered through an MA plan. HMOs continue to account for the majority (62%) of all plans offered in 2021.​
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Managed Care Resources

 Managed Care Playbook - 2018
The Managed Care Playbook (2018) is designed to assist AHCA/NCAL members operating Skilled Nursing Facilities (SNFs) and Assisted Living Facilities (ALs) to better negotiate the terms of their agreements with MA and Medicaid Managed Care (MMC) plans. It is also intended to provide guidance on the following issues: 

I. The legal authority of the CMS and individual state governments to oversee, and intervene in, contractual relationships between SNFs/ALs and MA / MMC plans; 

II. Strategies to address common disputes between SNFs/ALs and MA / MMC plans; and

III. Legal actions available to SNFs/ALs to enforce their rights.

 Medicare Advantage Toolkit Module I-III
The Toolkit is comprised of three modules:




The modules provide insight into the Medicare Advantage program and MA plans, including how MA plans are paid and their obligations to CMS, providers, and beneficiaries. It also outlines the components of a Medicare Advantage provider contract, key terms, and provisions.

 ‭(Hidden)‬ Contract Assessment and Return on Investment (CARI) - 2000
The CARI​ tool walks providers through the process for evaluating and understanding the real Return on Investment (ROI) of their Medicare Advantage contracts, ultimately assisting providers in determining whether remaining a network provider is worthwhile, or if other strategies may be more advantageous for both the provider and the residents.​

 Contact Us
Senior Vice President, Reimbursement Policy and Market Strategy
Vice President, Reimbursement Policy & Population Health​

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